Spontaneous haemothorax and haemoperitoneum in Plasmodium vivax malaria

Although patients with Plasmodium vivax malaria usually recover from the disease without any sequelae, several complications do occasionally occur and these may need urgent invasive procedures, including surgery, and/or lead to fatal blood loss (Jacobs et al., 2005; Gockel et al., 2006; Maguire and Baird, 2010). Worryingly, the incidence of complications in P. vivax malaria, such as acute respiratory-distress syndrome or splenic rupture, appears to be increasing (Kasliwal et al., 2009). A case of P. vivax malaria complicated by spontaneous haemothorax (perhaps the first ever reported) is described below.

CASE REPORT

In October 2006, a 45-year-old man who had not travelled abroad was admitted to Gil Hospital, in the South Korean city of Incheon, with tertian fever. Several months earlier, he had gone fishing on Gangwha, an island, near the demilitarized zone, where P. vivax is endemic. On admission, he was found to be febrile (39·8°C) and a physical examination revealed right upper-quadrant tenderness and splenomegaly. Haematology revealed haemoglobin at 12·4 g/dl, a haematocrit of 35·1%, and 3290 leucocytes and 21,000 platelets/μl blood. The patient’s serum was found to have 2·5 mg total bilirubin/dl, 55 U aspartate aminotransferase/litre, and 31 U alanine aminotransferase/litre. A bloodsmear was found positive for P. vivax and a course of chloroquine was initiated. On day 4 of his hospitalization, the patient complained of a dull discomfort in his right upper abdomen. On the next day, haematological investigations revealed anaemia (8·4 g haemoglobin/dl), a haematocrit of 24·0%, a prothrombin time of 11·8 s, and 20 mg haptoglobin/dl. No malarial parasites were detected in a smear of peripheral blood prepared at this time. The patient claimed not be be suffering from haematochezia or melena, and his blood pressure and heart and respiration rates were all within ‘normal’ ranges. No physical evidence indicative of coagulopathy, such as petechiae, purpura or bleeding from intravenous injection sites, was observed and the patient had not suffered any abdominal trauma post-admission. An abdomino–pelvic scan by computed tomography (CT), performed to investigate the aetiology of the anaemia that had suddenly developed and the right upper abdominal discomfort, showed a haemoperitoneum (without a visible bleeding focus) and bilateral pleural effusion. The observed splenomegaly (longest dimension = 13·6 cm) and the multifocal, small, wedge-shaped low-density lesions seen in the subcapsular area of the spleen were considered indicative of splenic infarction. As the density of the pleural effusion on the CT scan indicated that the effusion was bloody, a diagnostic thoracentesis was performed. This confirmed that the effusion was bloody, holding 10·2 g haemoglobin/dl and 4300 leucocytes (70% lymphocytes, 10% polymorphonuclear cells, and no eosinophils)/μl, and giving a haematocrit of 32·5%. As the patient’s vital signs were stable and his anaemia did not worsen, he was simply observed and given supportive care. A week later, the anaemia, thrombocytopenia and fever had resolved, and the patient was discharged. He has since remained asymptomatic.

DISCUSSION

Although most cases of P. vivax malaria recover from the disease without complication, even if left untreated, a small percentage develops severe problems, usually involving the spleen (Maguire and Baird, 2010) — an organ that plays an important role in host defence against malarial parasites (Zingman and Viner, 1993).

In most cases, haemothorax is caused by chest trauma or by invasive procedures such as the insertion of a central venous line, thoracentesis or pleural biopsy. Spontaneous or non-traumatic haemothorax is much less common and has a wide variety of causes, the most frequent being neoplasm and anticoagulant use; other causes include vascular rupture, pulmonary infarction, pleural endometriosis, and conditions that alter coagulation, such as haemophilia, thrombocytopenia and anti-platelet therapy (Martinez et al., 1992; Haro Estarriol et al., 2006). Small haemothoraces may be observed in stable patients but severe or unstable cases require surgical intervention.

In the South Korean case described here, a CT scan revealed haemoperitoneum and bilateral haemothorax. There are several reports of haemoperitoneum (combined with a splenic rupture) in patients with malaria (Jacobs et al., 2005; Gockel et al., 2006; Jiménez et al., 2007) but, apparently, no previous reports of spontaneous haemothorax associated with the disease. In the present case, although the bleeding focus could not be accurately located in the CT scan, the haemoperitoneum was probably caused by a spontaneous splenic rupture with infarction. The probable cause of the haemothorax is harder to identify but there are two main possibilities. One is that the haemothorax was secondary to the haemoperitoneum. Anatomically, the pleural space is separated from the peritoneal space and it is uncommon for fluids from the two spaces to mix. In some ascitic conditions, however, such as liver cirrhosis, malignant neoplasm and (rarely) haemoperitoneum, peritoneal fluid can reach the pleural space (almost always the right pleural space), via direct transdiaphragmatic passage (Pratt and Shamblin, 1968). A second possible explanation for the haemothorax described here is that (independently of the splenic complications) a spontaneous haemorrhage happened in the patient’s supradiaphragmatic space. Human infection with P. vivax can induce anaemia and thrombocytopenia — via haemolysis, reduced cell deformity of (parasitised and nonparasitised) erythrocytes, increased splenic clearance, reduction of platelet survival, decreased platelet production, and increased splenic uptake of platelets — that are severe enough to provoke spontaneous bleeding and other haemostatic abnormalities (Gorski et al., 1993; Thapa et al., 2009; Bhatia and Bhatia, 2010).

Physicians, who deal with malaria should consider the possibility of internal spontaneous bleeding, including haemothorax.